Microsoft Word - 1_AMQ, Part 1.doc
ADULT MEDICAL QUESTIONNAIRE
Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges.
Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan.
First Name:Middle Name:Last Name: Address:City:State:ZIP:
Home Phone: ()-_Birth Date:_/_/Age:
monthdayyear
Work Phone: ()-_
Place of Birth:
Occupation:City or town & country if not US Referred by:Height: Weight:Sex: Todays Date
1. Please check appropriate box(es):
African American
Hispanic
Mediterranean
Asian
Native American
Caucasian
Northern European
Other
2. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:
DESCRIBE PROBLEM
MILD/ MODERATE/ SEVERE
TREATMENT APPROACH
SUCCESS
Example: Post Nasal Drip
Moderate
Elimination Diet
Moderate
a.
b.
c.
d.
e.
f.
g.
Copyright The Institute for Functional Medicine
3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister
Adult Medical Questionnaire
4. Do you have any pets or farm animals?Yes
No
If yes, where do they live?1.indoors 2.outdoors3.both indoors and outdoors
5. Have you lived or traveled outside of the United States?Yes
No
If so, when and where?
6. Have you or your family recently experienced any major life changes?Yes
No
If yes, please comment:
7. Have you experienced any major losses in life?Yes
No
If so, please comment:
8. How important is religion (or spirituality) for you and your familys life?
a. not at all important
b. somewhat important
c. extremely important
9. How much time have you lost from work or school in the past year?
a. 0-2 days
b. 3 14 days
c. > 15 days
10. Previous jobs:
11. Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.
Please do your best to answer the following questions:
a. Did you feel safe growing up?
D YesD No
b. Have you been involved in abusive relationships in your life?
D YesD No
c. Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
D YesD No
d. Do you currently feel safe in your home?
D YesD No
e. Do you feel safe, respected and valued in your current relationship?
D YesD No
f. Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
D YesD No
g. Would you feel safer discussing any of these issues privately?
D YesD No
12. Past Medical and Surgical History:
ILLNESSES
WHEN
COMMENTS
a.Anemia
b.Arthritis
c.Asthma
d.Bronchitis
e.Cancer
f.Chronic Fatigue Syndrome
g.Crohns Disease or Ulcerative Colitis
h.Diabetes
i.Emphysema
j.Epilepsy, convulsions, or seizures
k.Gallstones
l.Gout
ILLNESSES
WHEN
COMMENTS
m.Heart attack/Angina
n.Heart failure
o.Hepatitis
p.High blood fats (cholesterol, triglycerides)
q.High blood pressure (hypertension)
r.Irritable bowel
s.Kidney stones
t.Mononucleosis
u.Pneumonia
v.Rheumatic fever
w.Sinusitis
x.Sleep apnea
y.Stroke
z.Thyroid disease
aa.Other (describe)
INJURIES
WHEN
COMMENTS
ab.Back injury
ac.Broken (describe)
ad.
Head injury
ae.
Neck injury
af.
Other (describe)
DIAGNOSTIC STUDIES
WHEN
COMMENTS
ag.
Barium Enema
ah.
Bone Scan
ai.
CAT Scan of Abdomen
aj.
CAT Scan of Brain
ak.
CAT Scan of Spine
al.
Chest X-ray
am.
Colonoscopy
an.
EKG
ao.
Liver scan
ap.
Neck X-ray
aq.
NMR/MRI
ar.
Sigmoidoscopy
as.
Upper GI Series
at.
Other (describe)
OPERATIONS
WHEN
COMMENTS
au.
Appendectomy
av.
Dental Surgery
aw.
Gall Bladder
ax.
Hernia
ay.
Hysterectomy
az.
Tonsillectomy
ba.
Other (describe)
bb.
Other (describe)
13. Hospitalizations:
WHERE HOSPITALIZED
WHEN
FOR WHAT REASON
a.
b.
c.
d.
e.
14. How often have you have taken antibiotics?
< 5 times> 5 times
Infancy/ Childhood
Teen
Adulthood
15. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
< 5 times> 5 times
Infancy/ Childhood
Teen
Adulthood
16. What medications are you taking now? Include non-prescription drugs.
Medication Name
Date started
Dosage
1.
2.
3.
4.
5.
6.
7.
8.
17. Are you allergic to any medications?Yes
No
If yes, please list:
18. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.
Vitamin/Mineral/Supplement Name
Date started
Dosage
1.
2.
3.
4.
5.
6.
7.
8.
19. Childhood:
Question
Yes
No
Dont Know
Comment
1. Were you a full term baby?
a. A preemie?
b. Breast fed?
c. Bottle fed?
2. As a child did you eat a lot of sugar and/or candy?
20. As a child, were there any foods that you had to avoid because they gave you symptoms?
Yes
No
If yes, please: name the food and symptom (Example: milk gas and diarrhea)
21. Place a check mark next to the food/drink that applies to your current diet. (List continues on next page.)
Usual Breakfast
Usual Lunch
Usual Dinner
a.
None
a.
None
a.
None
b.
Bacon/Sausage
b.
Butter
b.
Beans (legumes)
c.
Bagel
c.
Coffee
c.
Brown rice
d.
Butter
d.
Eat in a cafeteria
d.
Butter
e.
Cereal
e.
Eat in restaurant
e.
Carrots
f.
Coffee
f.
Fish sandwich
f.
Coffee
g.
Donut
g.
Juice
g.
Fish
h.
Eggs
h.
Leftovers
h.
Green vegetables
i.
Fruit
i.
Lettuce
i.
Juice
j.
Juice
j.
Margarine
j.
Margarine
k.
Margarine
k.
Mayo
k.
Milk
l.
Milk
l.
Meat sandwich
l.
Pasta
m.
Oat bran
m.
Milk
m.
Potato
n.
Sugar
n.
Salad
n.
Poultry
Usual Breakfast
Usual Lunch
Usual Dinner
o.
Sweet roll
o.
Salad dressing
o.
Red meat
p.
Sweetener
p.
Soda
p.
Rice
q.
Tea
q.
Soup
q.
Salad
r.
Toast
r.
Sugar
r.
Salad dressing
s.
Water
s.
Sweetener
s.
Soda
t.
Wheat bran
t.
Tea
t.
Sugar
u.
Yogurt
u.
Tomato
u.
Sweetener
v.
Other: (List below)
v.
Water
v.
Tea
w.
Yogurt
w.
Water
x.
Other: (List below)
x.
Yellow vegetables
y.
Other: (List below)
22. How much of the following do you consume each week?
a.Candy
b.Cheese
c.Chocolate
d.Cups of coffee containing caffeine
e.Cups of decaffeinated coffee